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Dated this ................ day of ................ A.D. ........, at ................ .
Dated this ................ day of ................ A.D. ........, at ................ .
Whereas on the ................ day of ................ at ................, A.B., hereinafter called the offender, (pleaded guilty to or was tried under (here insert Part XIX, XX or XXVII, as the case may be) of the Criminal Code and was (here insert convicted or found guilty, as the case may be) on the charge that (here state the offence to which the offender pleaded guilty or for which the offender was convicted or found guilty, as the case may be);
Whereas on the ................ day of ................ at ................, A.B., hereinafter called the accused, (pleaded guilty to or was tried under (here insert Part XIX, XX or XXVII, as the case may be) of the Criminal Code and was (here insert convicted or found guilty, as the case may be) on the charge that (here state the offence to which the accused pleaded guilty or for which the accused was convicted or found guilty, as the case may be));